Requests for Receipts must be submitted in writing via this form. Either print and fax this form or fill in and submit this form online via the web. Requests cannot be fulfilled via the telephone.

During peak time periods such as near tax time it may take 48 hours or longer to process the receipt request.

All receipts will be mailed or faxed to the requestor.

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Receipt requested for (fill in examination name)

Last Name First Name Middle Initial Suffix

Birthdate (mm/dd/yyyy)

Last four digits social security number (1234)

Primary Contact Phone (area code-xxx-xxxx ext)

email address (required)  

Select Method for Receipt to be returned:

US Mail to address provided below:

Company Name 
Address Line 1   
Address Line 2   
City State Zip Code

Fax receipt to number provided below:

(area code-xxx-xxxx)      

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